Confidential Patient Information Form

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Confidental Patient information

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  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Due to changes in health insurance fees, patient self billing has become a much more cost effective way for you, the patient, to get reimbursement for your care. Self billing allows us to keep our fees low so you can get the care you need without any added cost. Therefore, our policy is that all payment is due at the time of service and bills will no longer be sent to your insurance provider. Statements will be provided for individuals to submit their own bills ensuring that as your insurance provider pays for your care, they will send the reimbursement check directly to you.

  • All charges are due when services are rendered...

  • Why Chiropractic? People go to Chiropractors for a variety of reasons. Some go for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your Doctor will weigh your needs and desires when recommending your treatment program. Please Circle the type of care that best meets your needs.

  • I authorize Kremer Family Chiropractic to render necessary services to me and understand that I am responsible for all charges incurred.

  • Date Format: MM slash DD slash YYYY
  • THANK YOU FOR ALLOWING US TO SERVE YOU!